A Modification of the Tennison-Type Lip Repair THOMAS D. CRONIN, M.D., F.A.C.S. Houston, Texas After experience with the Blair-Brown (1) procedure, the Brown- McDowell (4) modification, the LeMesurier (6), the Tennison (10), and the Millard (8), my feeling is that the Tennison-type procedure is per- haps the best all-around operation for most single (unilateral) cleft lips. ‘The Millard operation comes next, with possible precedence in the case of incomplete cleits, and definite precedence for very slight clefts. In 1952, Tennison (10) deseribed his operation with emphasis on his method of marking the lines of incision with a wire stencil. I believe that his most important contribution was not in his use of a stencil, but rather in the preservation of the eupid’s bow by lowering the peal in the margin of the cleft. In his paper, he merely mentioned ‘preservation of the eupid’s bow’ as one of the requirements of good lip operation. In 1953, Marcks and his associates (7), in 1958, Hagerty (5), and in 1959, Randall (9) further elaborated on this type of operation, explaining the rational of the procedure together with accurate methods of marking, Referring to Figure 1 A, it is difficult to fit the pointed flap C-D-X into place and to secure accurate alignment of the vermilion ridge and proper thickness of the vermilion, In addition, there is a tendency, some~ times, for confusion of the vermilion ridge with the oblique sear C-D as they join (Figure 2). Since 1956, I have terminated the oblique incision C-D 1 mm above the vermilion. The latter is then erossed at right angles D-H, simplifying the adjustment of the vermilion both as to thickness and alignment (Figure 1B), Tennison (11) has made a somewhat similar change. Repair of the lip is usually delayed until the infant has attained a weight of 10 pounds or more, and is usually performed under intra- tracheal anesthesia, although, for those who prefer, local anesthesia may be used. Dr. Cronin is Clinical Professor (Plastic Surgery), Baylor University College of Medicine; Associate Professor, Post-graduate Medical School (Plastic Surgery), Ui versity of Texas; and Chief of Plastic Surgery Service, Hermann Hospital, St. Luke's Episcopal Hospital, and Texas Children's Hospital. He is Diplomate of the American Board of Plastic Surgery. ‘This paper was presented at the 1965 Convention of the American Cleft, Palate As- sociation, New York City. 376‘TENNISON-TYPE REPAIR 377 FIGURE 14. Usual appearance of a Tennison-type repair with the scar joining the vermilion border obliquely. FIGURE 1B, Modification with scar C-D ending 1mm above vermilion so that a vertieal ent D-E can be made across the vermilion, FIGURE 2. BJ, left, and W. T., right, two children demonstrating confusion of the vermillion ridge by the oblique scar of the usual Tennison-type operation. Technique In 1959, my associate, R. O. Brauer, and I (2) observed the tendency of the lip on the cleft side to become too long in a vertical direction as the child grows. This has been observed as a result of all methods and especially of the LeMesurier procedure. Therefore, the plan to be pre sented deliberately results in a 1 mm shortness in the line of repair (Figure 3). ‘The medial, or uncleft side, should be marked first. Then the follow- ing steps are suggested. a) Measure the length of the uncleft side of the lip as described by Brauer ($) (Figures 5, 6, and 7). Locate A” at the base of the columella, Place E” at the peak of the eupid’s bow. The distance A”—E” is the vertical length of the lip and, in infants of about. two months old, is about 10 mm, Therefore, the planned length of the378 Cronin FIGURE 3. Left, C. C, a child with a lip apparently too short on the repaired side. Right, ©. C. one and one-half years later. Spontaneous correction with growth. FIGURE 4. Left, C, H. a few days post-operative lip repair. The lip is slightly long in tho line of repair. Right, C. sx years Inter. The lip is even longer on ‘the repaired Fraure 5. Froune 6. FIGURE 5, Diagram of mothod of marking lines of incision, See text for details, FIGURE. 6. Diagram showing how the lip is fitted together.TENNISON-TYPE REPAIR 379 FIGURE 7. Leit, D. G., markings for a modified Tennison-type operation. Right, D. G. two years later. lip in the line of repair will be 1 mm less, or 9 mm. b) Tdentify the center of the lowest part of the eupid’s bow and label it X. ¢) At a distance equal to Z’-X, locate the peak of the cupid’s bow on the cleft margin and label it Z. This point should be near the end of, but still on, the vermilion cutancous ridge (7). A continuous vermilion cutancous ridge is essential because a gap immediately calls attention to the lip. d) Draw a line at right angles to the vermilion ridge through E, extending 1 mm on to the skin to D and all the way across the vermilion. c) Draw a line B-C about 4 mm in length, beginning at the vermilion border and passing through point D. (Experience has shown this to be a suitable length.) ‘This line should form a somewhat acute angle with the vermilion ridge so that the flap C-D-B-X will rotate downward easily. If the line C-B is made at, 90° or more it cannot be rotated downward as well. Line C-B should never extend beyond A”-E”, since this would re- sult in an inerease in the vertical length of the normal side of the lip. Line C-B is 1 mm longer than line C-D. For practical purposes, D-E is the same length as D-B. 4) Point A is placed at the base of the columella, Some help in locating this point is obtained by placing a small skin hook in the angle between the columella and ala and Hiting up to level corresponding with the normal side, Points A and B are connected. ¢) On the cleft side, place H’ at the most medial point where the vermilion is still of full thickness and the vermilion ridge is still present. h) Draw a line at right angles to the yermilion ridge through ’, extending 1 mm on to the skin to D’ and all the way across the vermilion. i) Point A’ is located at the base of the ala so that, when it is approximated to 4, the ala will be symmetrical with the normal side, i) The normal side of the lip is 10 mm, but as mentioned previously, it is planned to make the lip 1 mm shorter (or 9 mm in length) on the re- paired side, The distance 4B’ must be equal to A-B. The sum of 4B’380 Cronin and D’-K’ subtracted from 9 mm, the planned length of the lip on the repaired side, gives the dimension of the base of the triangular flap B’-C-'D’, One compass is centered at A’ with the points separated by the distance equal to A~B, Another compass is centered at D’ with its points set at the desired width of the base of the flap. Point B’ is placed at the point where these two ares intersect. k) Point C’ is located as follows: C’—B’ must be equal to C-B and C’-D’ must be equal to C-D. With two compasses set at these distances respectively, points are centered at B’ and D’ and the point of intersee- tion of their ares is marked C’, ‘When the points have been marked, as directed, on the skin surface, a 25 needle is dipped in Methylene blue and the skin is punctured at each point, thus making a mark which will not wash away. These points are connected as shown in the diagram. One to 1%4 ce of 1% xylocaine with 1:100,000 adrenaline is infiltrated sparingly in the sulcus and area of operation, being careful to distort the lip as little as possible. After 8 to 10 minutes to get the vasoconstrictive effect of the adrenaline, the mucosa in the sulcus is incised and the lip tissues dissected off of the periosteum only enough to secure approxima- tion of the lip. Now, with a wooden tongue blade placed beneath the lip and held there firmly by an assistant, the lip is further fixed by pressure near the line of incision with the index finger of the operator's left hand. ‘The lip is incised with a #15 blade, being careful to cut exactly along the lines and at right angles to the skin surface. The blade is pressed on through the lip to the tongue blade, If necessary, any small bits of tissue not severed by the knife are cut with a pair of pointed iris scissors. The cuts D-B and D/-B’ are made all the way thru the vermilion, care being taken not to extend the cut into the depth of the lip beyond points D and D’, since this would have the effect of making the lines D-E or D'-E’ too long. ‘The incision is extended up into the nose, as needed, beyond points A and 4’, Now a 4-0 plain catgut suture is inserted into the muscle be- neath the ala and columella and pulled snug to test for proper alignment. Ii satisfactory, it can be tied. Then the parts of the lip are interdigitated, one 4-0 plain eatgut suture being used in the muscle to bring each point well into the opposite angle. No more musele sutures are used. The vari- ous skin angles are next approximated with fine sutures and needle, such as 6-0 dermalon. The vermilion ridge is carefully aligned with a suture on each side of it, rather than in the ridge, thus avoiding the possibility of mutilating the ridge with a suture sear. The mucosal surface is sutured with 4-0 plain catgut, completing the repair. Some results of this tech- nique are shown in Figures 8 and 9, ‘An antibiotic ointment is applied to the suture line, followed by a small dressing to take up the exudate. The dressing is removed at 24 hours and‘TENNISON-TYPH REPAIR 381 FIGURE 9. C. R,, before (left) and after (right) repair, the lip is left exposed. About half the sutures are removed on the third post-operative day and the remainder on the following day. The lip is supported for about a week after this with a strip of wide mesh gauze and U.8.P. collodion (not flexible). Some vertical contracture usually occurs within two to three weeks, but this gradually stretehes out within several months. Summary A slight modification of the Tennison-type lip repair is described in whieh the oblique incision, instend of ending at the vermilion border, is terminated 1 mm above the border. A vertical cut is then made across the vermilion, making it easier to align the vermilion border, reprints: Thomas D. Cronin, M.D. 5419 Caroline Blvd. Houston, Texas 77004 References 1, Bua, V. P., and Brown, J. B., Mirault’s operation for single lip. Surg. Gyn. Obst., St, 81-98, 1930. 2. Braver, R. O., A comparison of the Tennison and LeMesurier lip ropairs, Plastic veconst?. Surg., 28, 249-259, 1959,382 Cronin 8, Braver, R. O., A consideration of the LeMesurier technic of single harelip repair ‘with a new concept as to its use in incomplete and secondary harelip repairs. Plastic reconstr, Surg., 11, 275-289, 1953. 4, Brow, J. B, and McDows11, F., Simplified design for repair of single cleft lip. Surg. Gyn. Obst., 80, 12-26, 1945, 5, Hacewry, R., Unilateral cleft lip repair. Surg. Gyn. Obst., 100, 119-122, 1958. 6, LeMrsomn, A. B,, A method of cutting and suturing the lip in the treatment of ‘complete unilateral clefts, Plastic reconstr. Surg. 4, 1-12, 1949. 7. Manoxs, K, M, Taevasxts, A. E,, and paCosta, A., Further observations in cleft lip repait. Plastie reconstr. Surg., 12, 392-402, 1953. 8, Mituarn, D. R., A radical rotation in single harelip. Amer. J. Surg., 95, 318-822, 1958. 9, Raxnat, P., A triangular flap operation for the primary repair of unilateral clefts of the lip, Plastic reconstr. Surg., 23, 381-347, 1958. 10, Texs1sox, C. W., The repair of unilateral cleft lip by the stencil method. Plastie re~ constr. Surg., 9, 115-120, 1952. 11, Taxsason, C. W., Personal communication.